Functional class, frequent decompensations, left ventricular ejection fraction (LVEF), cardiac hemodynamics, peak exercise oxygen consumption (peak VO2), and neurohormonal aberration have prognostic value in patients with advanced heart failure. At our center, these parameters are measured in patients referred with advanced heart failure to assess severity of heart failure and medical need for cardiac transplantation. If prognostic indicators are poor and cardiac hemodynamic parameters as measured by right heart catheterization are markedly abnormal, patients undergo intensive treatment in the Coronary Care Unit with a 48 to 72 hour intravenous infusion of the inotrope/vasodilator milrinone, to improve hemodynamics and clinical status. Intravenous milrinone is a phosphodiesterase inhibitor that has both positive inotropic as well as peripheral and pulmonary vasodilatory effects and results in increased cardiac output, decreased pulmonary capillary wedge pressure, decreased systemic vascular resistance and improvement in heart failure symptoms. After intravenous milrinone infusion is completed, oral vasodilator therapy with angiotensin converting enzyme inhibitors (ACEI) and/or hydralazine/nitrate combination are titrated to therapeutic doses and oral diuretics are optimized under right heart catheter guidance to maintain the improved hemodynamic and clinical status.